From the Guidelines
Milrinone should be used with caution in patients with acute decompensated heart failure and cardiogenic shock, due to its potential to increase the risk of postoperative atrial fibrillation (POAF) and other arrhythmias, as seen in a study published in 2024 1. The medication works as a phosphodiesterase-3 inhibitor, increasing cardiac contractility and causing vasodilation, thereby improving cardiac output. The typical dosing begins with a loading dose of 25-75 mcg/kg administered intravenously over 10-20 minutes, followed by a continuous infusion of 0.375-0.75 mcg/kg/minute, as recommended by the European Society of Cardiology in 2008 1. Milrinone is particularly useful in patients with reduced ejection fraction who have not responded adequately to diuretics, vasodilators, or other conventional therapies. It's also valuable in managing right ventricular failure and pulmonary hypertension. However, the medication should be used cautiously in patients with renal impairment, as it requires dose adjustment, and it should be avoided in patients with severe aortic or pulmonic valvular disease. Common side effects include hypotension, arrhythmias, and headache. Milrinone works by inhibiting the breakdown of cyclic adenosine monophosphate (cAMP), which leads to increased intracellular calcium in cardiac myocytes, enhancing contractility without significantly increasing myocardial oxygen demand compared to other inotropes. Some key points to consider when using milrinone include:
- Its potential to increase the risk of POAF, as seen in a study published in 2024 1
- Its use in patients with cardiogenic shock, where it can help optimize perfusion to vital organs, as discussed in a study published in 2018 1
- Its comparison to other inotropes, such as dobutamine, which may have similar clinical outcomes, as seen in a study published in 2018 1
- Its potential to cause systemic hypotension and arrhythmias, as discussed in a study published in 2008 1.
From the FDA Drug Label
Milrinone Lactate Injection is indicated for the short-term intravenous treatment of patients with acute decompensated heart failure. The primary use of milrinone is for the short-term intravenous treatment of patients with acute decompensated heart failure 2.
- Key uses:
- Treatment of acute decompensated heart failure
- Inotropic and vasodilatory effects in patients with congestive heart failure 2
- Administration: Intravenous injection or infusion.
From the Research
Milrinone Uses
- Milrinone is used in the treatment of end-stage heart failure patients who are refractory to optimal medical therapy 3.
- It can be employed as a home infusion therapy or a bridge to cardiac transplant 3.
- Milrinone is used in the treatment of acute decompensated heart failure (ADHF) 4, 5, 6, 7.
- It is used as an inotropic support in patients with low output syndrome 5.
- Milrinone may have a bidirectional effect based on etiology in decompensated HF, being potentially deleterious in ischemic HF, but neutral to beneficial in nonischemic cardiomyopathy 6.
Comparison with Other Treatments
- Milrinone was associated with a lower risk of mortality in patients with ADHF compared to dobutamine 4.
- Milrinone was also associated with improved mortality in patients with ADHF with destination therapy 4.
- There was no difference between milrinone and dobutamine in terms of acute kidney injury, initiation of renal replacement therapy, mechanical ventilation, arrhythmias, symptomatic hypotension, and length of hospital stay in the overall population 4.
- Dobutamine was associated with higher short-term out-of-hospital mortality compared with milrinone in patients with ADHF 7.
Patient Selection
- Milrinone is infrequently used or avoided entirely in patients with acute renal failure or end-stage renal disease because the drug is primarily cleared by renal excretion 3.
- The choice of milrinone or dobutamine may depend on the etiology of heart failure, with milrinone potentially being more beneficial in nonischemic cardiomyopathy 6.